Chap 115 Popliteal disease Flashcards
What is adventitial cystic disease?
disease where mucin containing cysts form in the arterial wall
Where is most common locations?
85% popliteal
then EI, Fem, but can be anywhere
can be in veins
What age, sex predominance?
M:F 5:1, mid 3s, women can be mid 50s
prevalence of ACD?
1 in 1200 claudicants, 1 in 100 diagnostic angio
what causes ACD?
repetitive trauma theory ganglion theory systemic disorder theory developmental theory (most accepted) cellular inclusion theory, mucin implanted in adventital wall during development
what are the pathological findings in ACD?
cyst with gelatinous mucoid material in adventitial layer
what does the popliteal artery look like
sausage like, cyst are unilovularr
what is the presentation of ACD?
sudden onset of claudication, short distance, usually calf, unilateral
CLI unlikely
what is differential for ACD?
popliteal entrapement, premature athero
what is PE?
Normal or diminished pulses, bruit in pop fossa
what is ishikawa’s sign?
pedal pulses present at rest disappear with flexion of the knee
how is ishikawa’s sign different then findings in PAES?
pedal pulses disappear with gastroc muscle contraction by active plantar flexion or passive dorsiflexion of the foot
What is presentation of venous?
similar to DVT, painless swelling
What test to perform?
NIVs–# and presenve or cysts, elevated doppler studies
angio–must look at ateral projections, appearance is eccentric stenosis with no post-stenotic dilation, if occluded may not be useful
CT/MRI–can differentiate b/w PAES
what are treatment options?
stenosed–transluminal angio, image guided aspiration, or operative cyst evac and excision
occluded– arterial resection and reconstruction
what is the risk of recurrence for different treatments?
angioplasty 100%
image guided asp 0-33%
operative cyst evac and excision 6-33%
arterial resection and recon 0-6%
Which is more common PAES or ACD
PAES
60% of young claudicants
What % are bilateral?
1/3
How does the gastrocnemius develop normally?
medial head rises from post fibula and lateral tibia
migrates across popliteal fossa to final attachment on posterior aspect of medial femoral condyle
popliteal artery forms superficial to the popliteus muscle at same time
What is the classification of popliteal entrapment syndrome?
type I
PA completes devel before medial head migration. artery pushed medial and lies medial to gastric
normal attachment site
Type II
artery displaced medially but medial head has variable attachment in lateral aspect go medial fem condyle
abnormal attachment site
Type III
abnormal muscle slip that arises from medial or lateral fem condyle
Type IV
persistence of axial artery remains deep to the popliteus muscle or fibrous band
Type V
cause by any of the other toes but vein also involved
Type VI
functional entrapment
What is the pathophysiology of PAES and what are the stages?
fibrosis leads to occlusion/thrombosis
stage 1 in the adventitia stage 2 in the media stage 3 in the intima and becomes thrombogenic
What are the classes of presentation for PAES?
class 0 asympto class 1 pain, parathesia, cold feet after physical class 2 claudication while walking >100m class 3 claudication while walking <100m class 4 rest pain class 5 necrosis
What provocative manoeuvres to perform for PAES?
pedal pulses disappear with gastroc muscle contraction by active plantar flexion or passive dorsiflexion of the foot
What investigations?
NIVS
CT and MRI to identify anomalous muscle
What is treatment for PAES?
release of entrapment
restoration of normal anatomy
restoration of flow
if artery normal and Type I or II–myotomy via medial approach
if III of IV myotomy via posterior approach
V and VI either approach
What angiographic findings can be associated with CAD?
- Arterial stenosis (smooth tapering)
- Artery prox to lesion is free of atherosclerosis
- If cyst is concentric it produced “Hour Glass” appearance. If eccentric: “Scimitar”
- Arterial occlusion (late)
